The public health significance of many medical, psychiatric, and neurological conditions and/or disorders is often overlooked, probably because of their episodic nature and the lack of mortality attributed to them. However, some medical conditions, such as headaches and facial pain, are often incapacitating, with considerable impact on social activities and work, and may lead to the significant consumption of drugs.
Migraine headaches are a particular form of headache, usually very intense and disabling. Migraines are a neurological disease thought to be of vascular origin. Migraines are characterized by attacks of sharp pain usually involving one half of the skull and accompanied by nausea, vomiting, phonophobia, photophobia and occasionally visual, olfactory or balance disturbances known as aura. The symptoms and their timing vary considerably among migraine sufferers and, to a lesser extent, from one migraine attack to the next. Migraine is often connected with the expansion of the blood vessels of the head and neck.
Migraine headaches can accompany, or be confused with, other types of headache, such as tension headaches. Since the treatment for other forms of headache may differ from that for migraine, it is important to recognize when migraine, tension or other forms of headache are occurring. In some cases, migraine headaches can cause seizures. Additionally, stroke symptoms (passing or permanent) are seen in very severe subtypes.
Migraine headaches often run in families and frequently start in adolescence, although some research indicates that it can start in early childhood or even in utero. Migraines occur more frequently in women than men, and are most common between ages 15-45, with the frequency of attacks declining with age in most cases. Because their symptoms vary, an intense headache may be misdiagnosed as a migraine by a layperson.
Conventional treatments for migraines focus on three areas: trigger avoidance, symptomatic control, and preventive drugs. Each of these will be discussed below.
In a minority of patients, the incidence of migraine can be reduced through diet changes to avoid certain chemicals that serve as a trigger for the migraine. These chemical triggers may be present in such foods as cheddar cheese and chocolate, and in most alcoholic beverages. Other triggers may be situational and can be avoided through lifestyle changes. Such triggers may include particular points in the menstrual cycle, certain weather patterns, or hunger. Bright flashing lights may also be a trigger. Most migraine sufferers are sensitive to and avoid bright or flickering lights.
If a migraine occurs despite trigger avoidance, the next step in treatment is symptomatic control. Caffeine and simple pain killers, analgesics, such as paracetamol, aspirin or low doses of codeine are sometimes, but not often, effective. Anti-emetics by suppository or injection may be needed in cases where vomiting dominates the symptoms. Generally, the earlier these drugs are taken in the attack, the better their effect. Narcotic pain medications, such as heroin, morphine, and other opiates, provide variable relief. However, their side effects and ability to cause serious drug addiction contraindicates their general use.
Sumatriptan (Imitrex®) and the related 5-hydroxytryptamine (serotonin) receptor agonists are now available and are the therapy of choice for severe migraine attacks. They are highly effective, reducing or abolishing all the symptoms within 30 to 90 minutes. These drugs have few side effects if used in correct dosage and frequency. However, about 20-30% of patients do not respond.
Evidence is accumulating that these drugs are effective because they constrict certain blood vessels in the brain. They do this by acting at serotonin receptors on nerve endings. This action leads to a decrease in the release of a peptide known as CGRP. In a migraine attack, this peptide is released and may produce pain by dilating cerebral blood vessels.
In addition to treating symptoms, preventive medication may also be administered on a daily basis if attacks occur more often than every two weeks. A large number of preventative medications with varying modes of action can be used. Selection of a suitable medication for any particular patient is a matter of trial and error, since the effectiveness of individual medications varies widely from one patient to the next. Beta blockers such as propranolol and atenolol are usually tried first. Antidepressants such as amitriptyline may be effective. Antispasmodic drugs are used less frequently. Sansert was effective in many cases, but has been withdrawn from the U.S. market.
Migraine sufferers also usually develop their own coping mechanisms for intractable pain. A cold or hot shower directed at the head, less often a warm bath, or resting in a dark and silent room may be as helpful as medication for many patients.